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Probability diagnosis

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Haemorrhoids/perianal haematoma

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Anal fissure

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Colorectal polyp

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Diverticulitis

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Excoriated skin (anal pruritus)

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Serious disorders not to be missed

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Vascular:

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  • ischaemic colitis

  • angiodysplasia (vascular ectasia)

  • anticoagulant therapy

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Infection:

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  • enteritis (e.g. Campylobacter, Salmonella)

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Cancer/tumours:

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  • colorectal, caecum

  • lymphoma

  • villous adenoma

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Other:

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  • inflammatory bowel disease (colitis/proctitis)

  • intussusception

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Pitfalls (often missed)

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Rectal prolapse

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Anal trauma (accidental/non-accidental)

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Villous adenoma

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Rarities:

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  • Meckel diverticulum

  • solitary ulcer of rectum

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Key history

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Nature of the bleed, including fresh versus altered blood, mixed with faeces and/or mucus, in toilet bowl or on underwear. Quantity of bleeding: slight, moderate or torrential. Associated symptoms (e.g. weight loss, constipation, diarrhoea, pain, weakness, presence of lumps, urgency, unsatisfied defecation, recent change of bowel habit).

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Key examination

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  • General inspection (evidence of anaemia) and vital signs

  • Abnormal examination, anal inspection, digital rectal examination, proctosigmoidoscopy

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Key investigations

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  • FBE and ESR

  • Stool M&C

  • Faecal occult blood

  • Colonoscopy

  • Consider abdominal X-ray, CT colonography, angiography, small bowel enema (depending on clinical findings)

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Diagnostic tips

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  • Black, tarry (melaena) stool indicates bleeding from upper GIT: rare distal to lower ileum.

  • Frequent passage of blood and mucus indicates a rectal tumour or proctitis.

  • If substantial haemorrhage, consider diverticular disease, angiodysplasia or more proximal lesions (e.g. Meckel diverticulum, duodenal ulcers).

  • New bleeding age >55 years demands colonic investigation.

  • 80% of rectal tumours are within fingertip range.

  • In young adults, diagnosis is likely to be haemorrhoids or a fissure.

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